If it hurts, it may be in a tissue...

August 30, 2012 at 10:44 PM · I really wish we could play without any pain for as long as we live, but in reality, most if not all string players have to, like athletes, deal with pain, especially chronic pain, at some point of our life. Jeewon Kim, in his replies to my recent blog on pain and suffering, provided tons really good tips and resources on how to deal with this problem. I thought it's worth sharing with everyone here, just in case you’ve missed. For example,this five minutes video summarizes the recent science on pain.

Thanks again, Jeewon!

Replies (26)

August 31, 2012 at 03:36 PM · Chronic pain is one thing. It usually caused by neuropathy - damage to the nerves themselves. Pain from chronic stress / re-injury is another completely different thing. Many violinist who think they have chronic pain, really have chronic severe stress because of improper, very tense technique. When small muscles are tensed for hours of practice every day, they eventually inflame and/or strain. The solution is not yoga, massage, etc., the solution is to change to technique that is relaxed and fluid.

September 1, 2012 at 05:49 PM · I think Yixi framed her discussion on pain and suffering perfectly by speaking of its significance. That's exactly what the latest research is suggesting, just from the brain's perspective.

From an article by G. Lorimer Moseley (see him in this Ted talk on Why Things Hurt):

"This issue was actually settled a couple of decades ago – there is not an isomorphic relationship between pain and nociception, nor between pain and tissue damage [2]."

Research shows rather, that the brain "modulates" or interprets signals from nociceptors (sense receptors which detect noxious stimuli, events which could potentially damage tissue) according to three categories: prioritization (survival value of stimulus,) meaning (depending on context, the brain interprets a noxious stimuli as painful or not,) and transmission/processing (based on expectation.) Of the three Moseley believes meaning to be of most importance to pain science.

Although our conscious thoughts can have an effect on our experience of pain, the brain functions at a more primitive level, interpreting nociception and sending pain signals with or without our 'permission.' So pain is neither a simple one-to-one correlation to damaged tissue (skin, muscle, tendon, bone, nerve,) nor is it just deeply rooted negative thinking that we can talk ourselves out of. John's frozen shoulder, or phantom limb syndrome cannot be explained away as simply physical or psychological damage, but they are examples of the brain's powerful control over our mobility and pain, working the way it should to protect us from potential harm, just misinterpreting signals and\or context.

See also: Great New Paper on Targeting the Brain for Treatment of Pain

Here's what Paul Ingraham has to say about nerve damage:

"“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have nerve pain.”

Yes, you might. But it’s not bloody likely! For the reasons discussed above, the clinical reality is that neuropathy is a lot less common than patients and doctors believe — most of it is caused by myofascial pain syndrome."

Speaking of a former client: "However, a couple things didn’t add up. For instance, she had no numbness at all — no dead patches of skin, which are highly characteristic of true nerve impingement. Instead, she had a lot of “dead heaviness” in the leg. As discussed above, this is a different kind of numb feeling that is much more closely associated with trigger points than with nerve pinches — and a lot more common."

On microtrauma: "Microtrauma is a concept that often gets used without specific knowledge, like references to unspecified “toxins” or “quantum.” Repetitive strain injuries are well-known not to involve microtrauma in a mechanical sense, but complex metabolic failures.4 It is also unlikely that “microtrauma” has anything to do with other chronic pain and injuries that don’t heal. Ironically, the only common painful condition where microtrauma is still a candidate is the muscle soreness you get after intense exercise — but it’s controversial even there,5 this is a minor temporary condition, and not one you want deep massage for.6 It’s also a mystery what kind of physical therapy might help microtrauma, even if it is present and clinically meaningful … but almost certainly not strong massage, or the pin-and-stretch technique in particular."

While it's true that changing setup and posture have the potential to help with pain (though not for the reasons, or to the extent we might expect; see Stand Up Straight,) it might have much more to do with the quality of our movement and the clarity of our brain maps which control them. See Strategies to Reduce Chronic Pain, Part One. If we move in a rigid way we fatigue quickly. But how does that fatigue turn into chronic pain, which persists even when we cease the movement? Why is it that, more often than not, pain presents even with no tissue damage? How can an amputee feel pain from a missing hand? How is it that a soldier can get to safety without feeling pain from an acute injury? These are some of the difficult questions pain science attempts to answer without resorting to a naive realism.

Why self-massage and mobility? They're cheap and have zero side-effects. Although it's difficult to get good research done on massage, there's more and more evidence of it's efficacy. Rest might turn out to be the best treatment for activity related chronic pain, but it might not be an option for a working musician, or an office worker, or a manual worker. Massage and mobility could be the difference between survival and collecting disability... but wait, most musicians don't qualify for disability payments. But perhaps most importantly, self-treatment leads to a better understanding of what hurts and where, what moves and how; we intentionally teach our brains more about the body it maps, and clarify a fuzzy representation, gradually showing it there's no longer anything to fear in whatever activity we chose to keep doing.

February 16, 2017 at 02:56 AM · Or, it may not be in the tissue. Since last December, I've increased my practice from 20 min/day to 2-3 hours/day working hard on a concerto, orchestra works and a chamber piece. I find my left shoulder feels a little uncomfortable and my left arm bicep gets fatigue-sort of ache within minutes of playing, but then it went away afterword lowering my left shoulder, which shouldn't be raised at the first place. In addition to paying attention to the setup and posture, any thought and suggestion on shoulder exercises will be much appreciated.

February 16, 2017 at 03:01 AM · I really hate it. I've player other instruments and had no problem at all, but with the violin, after 3 years playing, I still feel pain in the back, some days, others I don't. It's a weird posture, not matter how many times I've read "it's natural, you just don't do it right", I just don't buy it. I've played with SR and without SR. I think it takes like 10 years or more to find that perfect posture that no matter how many hours per day, every day, you play, you won't feel any pain never.

February 16, 2017 at 03:12 AM · Hi Yixi, glad you're doing much better! Me too :)

When I play too much (3 service days, or 8 shows/week, music without breaks (grrrr), etc.) I get the same thing. What get's me through is trigger point massage. Last summer, a very heavy season, I discovered all sorts of spots on the front (pecs, front deltoid, just underneath the collar bone, even behind the collar bone, weird places.) I don't know the names of these muscles because I never mapped it out, but just went by feel. That released all sorts of knots elsewhere, even in the shoulder blade and elsewhere. (I should really go to a pro!)

I've noticed that if I raise the hand above my shoulder socket I get into trouble much faster, so I keep my left elbow low, almost beside my ribs sometimes, but I guess this will affect the whole setup. I think any shoulder retraction exercise will help, like rows, but I've found exercising the mover muscles used in holding the fiddle doesn't relieve anything. Only change in my setup and the way I move has helped (since I injured my left shoulder over 10 years ago.)

The biceps and deltoid are synergists to raise the upper arm (shoulder flexion.) So it makes sense that dropping the upperarm would help. Say NO! to raised scrolls (for some people.)

~~~~~

Tim, it took me some 35 years to really get comfortable. I too went restless for a while (which helped undo a lot of excess tension, and taught me how to integrate my left hand with fiddle) but ultimately the setup was wrong for my proportions, and lead to injury, working 8 shows/wk on an unrelenting show. It really shouldn't take that long. I think it should take maybe 6 mos to a year to get comfortable, but there isn't a lot of info and equipment to help. Getting to know your own body use (the way Alexander Technique puts it) will help.

P.S. post some pics and/or video for comment if you like

February 16, 2017 at 03:58 AM · Jeewon, thanks! I secretly hoped you'd see my question and help, and it's very helpful indeed. Love to see more videos or pictures, anything you've got to share on this topic will be great!

"Say NO! to raised scrolls" I had a lesson today and raised the issue. My teacher also told me not to raise the scroll as I sometimes try to do, and suggested if I do it I should lean backwards by bending the waist instead of lifting. Her former student Timmy Chooi does this sometimes.

Tim, yes, back pain and, in my case, left knee strain if I don't work out. I practice standing most of the time. I think I might be habitually brace myself with my left leg. So if I forget to do some cardio and yoga after practice, my back and left knee will remind me they are not happy. I try to do at least 1/2 hr cardio and strength work each day plus a bit of yoga to stretch to minimize the discomfort.

February 16, 2017 at 05:07 AM · I don't know much about medical terms or exercises, other than the cliched "total relaxation" will help most players not only play injury-free, but also with amazing ease and facility. I generally try to find "tension points" and fix them as I notice them-be it on the bow arm, shoulders, pressing down, thumb, etc. Stress/tension/odd pressure/bad posture can make already technically difficult passages more challenging than they should be (and of course, sometimes mental fear of a passage can make you tense-we should all watch out for that.)

A rule I have is to listen to my body-pain or a nerve sending me a signal means I must do something different. Again, my focus is on eliminating tension as close to 100% as possible, since I am generally healthy and can meet the standard.

Though I understand it's more of a struggle when forced into situations where we can't relax as much, as mentioned in some posts above. Relaxing and resting fingers/hands/arms/muscles is paramount, IMHO, whenever we can afford to.

February 16, 2017 at 05:16 AM · For what is it worth:

https://www.muscle-joint-pain.com

February 16, 2017 at 06:10 AM · Rocky, this is very useful. The bits on anterior shoulder pain is just what I need. Thank you!

Adalberto, good reminder for relaxing whenever we can. I'm reworking on the 1st mvt of the Mendelssohn concerto. Among the technical and musical stuff, I usually try the same thing at least two ways: play it the sound I want and once I've achieved it, play it with less tension. When it comes to working on orchestra works though, especially during rehearsal, I tend to forget about the relaxing part.

February 16, 2017 at 03:58 PM · This is retraction: http://www.webmd.com/fitness-exercise/scapular-exercise-retraction

Rule of thumb: keep the shoulders retracted--imagine holding a coin, squeezed between the shoulder blades. Don't protract (i.e. don't push shoulders forward in row-type exercises.)

You can also use weights, or use a table of appropriate height. In life and violin playing, we mostly push the shoulders and arms forward, and hardly pull. E.g. while driving, keep the shoulders retracted. Bucket seats encourage us to keep the shoulders forward for which an upper back cushion might help. If you're a lefty, keep your elbow low and at your side using a mouse. Shoveling snow, a new pastime Vancouverites must love by now ;) keep the shoulders retracted when scooping.

The problem with rowing exercises for you might be the involvement of the biceps in the pulling motion, so you could just keep the arms straight and go from neutral to retraction and just hold it there for an isometric exercise. Or do something like this: http://www.therabandclx.com/dynamic-isometric-shoulder-retraction.html

But of course, as we know, pain or weakness is very complex, and not just about exercise and balancing muscles. It might be better in the long run to find a good movement professional (see https://www.bettermovement.org/blog/2017/experts-versus-gurus-whats-the-difference and take everything I suggest with a grain of salt, or maybe as a starting point, if you're in a generous mood. Speaking of Todd Hargrove, have you seen his new book, A Guide To Better Movement? CAN, US--chock full of all that good info we talked about, and Feldenkrais style exercises for ingraining better movement.)

February 16, 2017 at 04:07 PM · I had neck issues last year, not necessarily caused by the violin/viola but definitely aggravated by it. I got physical therapy and I wish I had done so sooner. One thing the physical therapist can teach you is how to know and understand your anatomy better. I got some stretching and strengthening exercises that are helping me a lot, and I'm able to practice again finally. So, even if you think the advice you got on an internet site is useful, or if you're managing your issue with self-prescribed therapies based on your own review of "recent science," a couple of physical therapy visits can be useful just for the education. Usually insurance covers it too, at least mine does. You just get a PT prescription from your doctor, hopefully one that just says "diagnose and treat." Also the physical therapist will measure your range of motion using standard tests and then track your progress as you go along, that's nice.

February 16, 2017 at 04:22 PM · I agree, as long as you find a great one... accreditation doesn't guarantee expertise.

Yixi, in terms of playing, you might try incorporating a shoulder retraction into your left arm technique. I think most people tend to curl the shoulder forward, curl the biceps to shift, play on G-string, do vibrato. Even lifting the upper arm, there can be a tendency to shrug, or push the shoulder forward.

It's possible instead to raise the whole arm using only shoulder retraction as a counterbalance. Not much, but enough to initiate a shift, for example.

Try:

1) leave arm hanging at side, completely relaxed. Engaging only retraction, raise the arm and release.

2) holding left arm in playing position, elbow bent, palm facing you, raise the upper arm using only retraction, and release.

3) start as in 2) but as you retract, throw the hand toward you, as in a shift

So instead of curling in on itself, you can incorporate retraction into your left arm technique.

February 16, 2017 at 06:51 PM · Jeewon, loads of great stuff. Just bought Todd Hargrove book. The retraction exercises are very doable in home or gym. Thank you!

Paul, I agree with you that a PT can ultimately help when the pain gets persistent and movements are limited. My experience with PTs is also somewhat interesting. I went to one PT based on his reputation as being a musician's PT (somewhat of a "in-house" PT for the professional orchestras, presumably at a special rate). He did a month work on me and declared I was good to go. But it didn't get better. So I went to my GP, who is a former military doctor and quite athletic. After X ray result ruled out more serious structural problem, she sent me to her PT, who is also a national competitive triathlete. We worked together a few months, first active release, then a few weeks of "shockwave therapy" (a electronic hammer taps on the shoulder to reinjured the tissues in a controlled way for recovery). Sounds a bit weird, right? Whether it was placebo or not, it worked as a charm within a couple of weeks, and my right shoulder has been fine since.

February 16, 2017 at 07:27 PM · I've not had such good luck with PTs, though I've never gone for myself. I had a student with shoulder problems. The PT looked at her, said her shoulders were too protracted, space between blades was too great, looked at her play the violin and just gave her a list of strengthening exercises to do, which I later discovered were pretty generic exercises to strengthen stabilizers (basically retraction exercises.) She gave no information or exercises or special insight you couldn't find by googling "shoulder stabilizing exercises," but of course we didn't have such a robust WWW back then. Didn't resolve the weakness and pain until we dealt with her posture while she played. Was it the stabilizer exercises or improving her use of her shoulders? Who knows. I'm sure the exercises helped her feel a new range of motion. But I'd argue you'd get the same and better info searching on your own today. Another PT (turned out to be from Stouffville Musicians' Clinic) prescribed stuffing a higher shoulder rest under the fiddle for a student with a very short neck, thereby increasing pain. I got her to use a $2 sponge and tweaked her setup, which seemed to help. This was years before my own injury, but got me started researching for myself. Yet another PT along with a GP diagnosed my former teacher with carpal tunnel (in both hands! how common is that?) when it turned out to be c6-c7 degeneration impinging on his spinal chord, hence the symmetry. Before seeing the neurologist who discovered the degeneration, he'd received carpal tunnel surgery on his left hand, thus ending his ability to play forever, and which did not resolve any numbness or pain. After fusing his c6-c7, he had worse pain and cramping in his left hand, forever, though his right hand improved, N.B. improved but did not heal completely. Caveat emptor! Knowing what I know now, I firmly believe he would've fully resolved the symptoms of his spinal impingement with movement therapy (using Alexander Technique or Feldenkrais Method) and come out of it with no fused neck, and would have continued playing. What a loss! Ah well, he sold his Storioni and bought a gigantic new house for his wife.

I understand it's only a sample size of 3 PTs and one GP. And I know it's important to rule out anything more serious. But sheesh!

Edit:

Physicians Misdiagnose at an Alarming Rate

  • An estimated 10 percent to 20 percent of cases are misdiagnosed, which exceeds drug errors and surgery on the wrong patient or body part, both of which receive considerably more attention.
  • One report found that 28 percent of 583 diagnostic mistakes were life threatening or had resulted in death or permanent disability.
  • Another study estimated that fatal diagnostic errors in U.S. intensive care units equal the number of breast cancer deaths each year -- 40,500.

http://www.ncpa.org/sub/dpd/index.php?Article_ID=23148

Edit2: wow! How did I go directly to a righty think tank! What's their agenda in publishing such findings I wonder... Dun dun duuuuuuun! I guess you always find the proof you're looking for. Where's House when you need him?

February 17, 2017 at 07:24 AM · Jeewon, this think tank smells bad. It appears to be a right wing think tank and partially funded by the insurance industry. This doesn't mean they are not telling some truth, of course, but I suspect their works are quite biased. They are not friends of the doctors. Besides, the article doesn't link to any peer reviewed material but linked to Kaiser, which is a large insurer.

February 17, 2017 at 12:17 PM · Yikes! Stinks! Vying world orders and what not. Truth is always stranger than fiction...

I was thinking about you and Tim and back pain. Is that mid, lower?

I used to throw out my lower back from time to time (not sure if that was playing related.) And I used to always feel a strain in my midback while playing. What helped me was realizing how stuck my thoracic spine had become. It wasn't responding to motion in the lower back and pelvis. And it had very little rotation, which caused greater rotation in lower back. Apparently you're supposed to stabilize the lumbar and rotate mostly at the thoracic when you twist.

Also, re. left knee pain, do you tend to always lean to one side, e.g. if you're just standing around waiting for something? Are you considered to have "flat" feet?

Edit: To be fair, the article they link to by Sandra G. Boodman, medical columnist for The Washington Post, does cite from what appear to credible sources.

http://www.ascopost.com/issues/august-15-2012/a-physician-who-is-also-a-cancer-patient-talks-about-medical-errors.aspx

http://www.hopkinscme.edu/CourseDetail.aspx/80028747

http://jamanetwork.com/journals/jama/article-abstract/1362034

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108559

http://qualitysafety.bmj.com/content/early/2012/07/23/bmjqs-2012-000803

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1656540

https://psnet.ahrq.gov/resources/resource/1546

quote from http://www.rti.org/news/mark-graber-named-rti-international-senior-fellow

article by http://jeromegroopman.com/how-doctors-think.html [broken link]

story from http://www.nytimes.com/2012/10/26/nyregion/tale-of-rory-stauntons-death-prompts-new-medical-efforts-nationwide.html

Edit2: on the other hand, it's her job to go looking for trouble!

February 17, 2017 at 04:29 PM · Jeewon, I do have flat feet and I notice, first thing in the morning, my left leg seems to have more tension than the rest of my body. I had sciatic in about 10 years ago was also on the left. Exercise and stretching eliminate the trouble, but discomfort occurs after long hour sitting and resting. I have no problem squatting, which I like to do on a daily basis, but I can feel the zap sometimes walking down stairs and running. Last October I was in Italy for a month and walked and climbed stairs and hills all day, no knee problem whatsoever.

February 17, 2017 at 05:51 PM · I have problems with my left leg too! I sprained my ankle playing pickup basketball in my 20's. I can't play basketball. Nearly blacked out and it hasn't been the same since. I tried one of those orthotics machines, where you step on it and it maps pressure points and the salesperson told me my left foot was flat, but not my right.

In the 90's I read a couple of books by Phil Maffetone, one of which, Fix Your Feet might be of interest to you. (Thought the info is similar to www.fixflatfeet.com below.) It turns out there's really no such thing as 'flat feet', but that you can control your arch by tweaking hip rotation in the legs.

Practicing against the wall for various reasons I became aware of a permanent rotation in my body. With by back to a wall, heels touching the wall, there's rightward rotation, so that my left shoulder, left butt-cheek and left calf, would tend to rotate away from the wall. I think this is a direct result of such a rotation in violin playing. I couldn't even straighten my leg so that my left calf would touch the wall. That's because by left leg had an inward rotation by default, which caused greater foot pronation resulting in a 'fallen arch,' which is actually caused by weak glutes.

A few years ago I found this blog: https://bretcontreras.com/

His marketing used to cater to fitness models, his main clients then, so some might be a bit put off by some of his marketing. But having read his book, Strong Curves, and many articles, and considering his creds, he's the real deal. Now that he's well known, he caters to a wider clientel. He says that any injury in the leg will cause the brain to shut down the powerful glutes, in an attempt to prevent further injury and allow it to heal. Over the long run, this preventative measure can become chronic without rehab, limiting mobility in the hip and causing further weakening of the glutes.

This is the idea behind how weak hips cause flat feet: https://www.fixflatfeet.com/hip-weakness/"https://www.fixflatfeet.com/hip-weakness/

If you have a habit of favouring standing on one foot over the other, that might be an indication of a weak hip complex on the other side. It took me a long while for it to feel normal to balance over my left foot, to centre it beneath me, whereas I've always easily leaned over my right hip.

Now I can stand flat against a wall, but I still feel my torso wanting to rotate away, a remnant of the strong imprint my old violin setup and left-side technique had over me.

Here are some Contreras resources:

A workout to help focus on glutes and the big hip muscles:

http://youtu.be/bK7zIUBH6Z0 (you might wanna turn off the sound if you're not into that kind of thing ;)

https://www.youtube.com/watch?v=vjrkegpbCjM It's about more than the shape!

https://www.youtube.com/watch?v=hCm-70-9_XEf Contreras' signature workout.

https://www.youtube.com/watch?v=RL2fZvCNjpM&feature=youtu.be Good video on bodyweight squats.

https://www.youtube.com/watch?v=juIHvANb4yk&feature=youtu.be Proper squat stance explained.

February 17, 2017 at 06:44 PM · Wow, Jeewon, amazing! I'm going to try the wall thing first. Thank you!

February 17, 2017 at 08:18 PM · Most welcome! I've also found a boxer's stance, slightly pigeon toed, prevents hip and torso rotation. I used to stand with a symmetrical, toes out at 45 deg, stance. But if you point your toe/knee (they should always point together) out, hip in external rotation, the pelvis is free to swing and tends to rotate, for violin, to the right. Look from behind and you'll notice most fiddlers push left shoulder forward and rotate right. If you give an internal rotation, point left toe forward or slightly right, it prevents the pelvis from rotating right. Also you can keep the arch elevated more easily with a static external rotation this way. Right foot can point slightly right. If you look at old school ideas, this is how they stood before the mid 20th C. The symmetrical stance happened quite recently I think. I also shift my weight from middle to left to right depending on context.

Clarification: I think what's happening is that by closing off the left hip by internal rotation, it rotates the pelvis a bit to the left. If you let it unwind to the right and rotate the torso, you're almost facing completely right. So to counter the unwinding of the hips, the torso and pelvis maintain their slight rotation left, keeping the torso from pushing forward/rotating right, or something like that. Sorry if that's still confusing. Hard to think/write about.

February 18, 2017 at 05:00 AM · So the right pointing of the left foot to tilt pelvis left feels good and solid so far. I actually have pretty strong legs and hip due to genetics and minimum 1 hour daily fast walk for many years. But I need more workout now since I am retired and tend to stay inside a lot. The videos are great and will give me a lot of ideas to integrate into my daily workout routine.

Thanks again, Jeewon!

February 18, 2017 at 05:00 AM · another double posting. This happens a lot lately.

February 18, 2017 at 05:00 AM · double posting

February 18, 2017 at 02:46 PM · That's great!

I don't know if you have a tendency to lock your knees, but combined with internal rotation and a fallen arch, that could lead to knee pain. Since learning how to squat properly (through a power lifting routine) and coordinate my spine, I always try to resume a slight feeling of squatting while I stand, not looking like I'm hovering over some imaginary hole in privy mind you, but enough to spread my weight at the mid-feet or heels. Some like to stay on the balls of their feet, but I like to feel grounded, rather than ready to sprint. Also, whatever the default stance, I think it's important to keep from getting stuck into any single posture. It took me a long while to even become aware of my own stucknesses..ses.es. What secrets do privy councillors hide in their chambers I wonder, speaking of bad smells and what not.

February 19, 2017 at 02:58 AM · Jeewon, the slightly pigeon toed stance really does the trick. After practiced standing for hours, the left knee feels no problem. Amazing! I used to lock my knees when I was younger but not any more -- older and wiser now ;) AT and yoga have helped me a lot on balance when I think about it. When practice, I tend to forget these things.

February 19, 2017 at 08:23 AM · That's great! And thanks for trying it out. I discovered my new stance, which turns out to be very old, years after I stopped teaching, so I've only been able to share it with a few graduates who've come back to play for me from time to time. Glad it's working for you too.

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